Osteoarthritis of the Knee: A Multimodal Rehabilitation and Treatment Approach
Osteoarthritis (OA) also called Degenerative joint disease (DJD) is the most common form of arthritis affecting the bone, cartilage and soft tissues within an articular joint. OA can be a painful condition leading to a loss of independence, functional impairment and inability to partake in daily activities such as walking stair climbing and other physical or sporting activities. Although OA is more common in the aging population, it is also found in younger sporting populations, affecting them later in life after knee trauma, such as Anterior Cruciate Ligament ACL) reconstruction and returning to high level of competitive sport.
Stiffness after prolonged sitting Stiffness early in the morning Grating or clicking sound on movement Reduced strength and mobility Mild swelling after activity
Loss of strength and muscle mass is considered to be an important risk factor in OA and associated with disease progression. A systemic Cochrane review of the literature found that exercise can reduce pain, improve function and quality of life.
To improve strength and muscle mass around the knee, a high resistance-training program must be implemented. Unfortunately many patients with OA find it hard to exercise at such intensities.
Recent research by (R B Ferraz et al 2018) using Blood Flow Restriction Training (BFRT), compared 3 groups over 12 weeks of lower limbs resistance training.
Group 1 High intensity training 80 % Maximum voluntary contraction (MVC) Group 2 Low-load exercise 30% MVC. Group 3 Low- load exercise 30% MVC with Blood flow restricted training (BFRT)
Low-Load exercise showed no improvements. However, the High intensity and the low-load with BFRT demonstrated clinically relevant increases in strength and muscle mass. The low-load group with BFRT had the same effect as the High intensity group with less pain in outcome measures, making it a very viable option for the adherence of exercise in OA.
There is also strong evidence to recommend hip muscle strengthening on knee pain and as a conservative management for knee OA.
Acupuncture and Trigger points
Reports of the therapeutic and analgesic effects of acupuncture in OA have stimulated interest in research, leading to a substantial body of evidence in favor of both Traditional Chinese Medicine and the modern biomedical model of acupuncture. Although both systems vary in their treatment methodology they have shown to be beneficial on improving mobility and demonstrated significant improvements on reducing pain and stiffness. The addition of electrotherapy to needles, such as electro-acupuncture and TENS has also proved to be effective.
There is a substantial body of evidence of Manual therapy techniques such as mobilization, manipulation, soft tissue and neural techniques in reducing both local and referred pain, increasing muscle activation decreasing stiffness and enhancing the range of movement within a joint.
Strategies for Runners with OA
Temporarily reduce the frequency, intensity or duration of your runs. Do not stop exercise, cross-train if in discomfort Increase your run step rate by decreasing over-stride Try a forefoot, or mid-foot running approach Be aware of pelvis position and mechanics Strengthen and condition the lower limb muscles
A Multimodal Approach
There are a variety of strategies that can help the patient with knee OA, including psychological and pharmacological approaches.
Research demonstrates compelling evidence regarding the benefits of a tailored exercise program on the management and treatment knee OA.
Pain often limits exercise adherence in the patient with knee OA using traditional high intensity exercise. The clinical and therapeutic potential of BFRT having the ability to increase strength and muscle mass without increasing loads on the articular joint is an encouraging option.
Manual therapies and acupuncture/ needling can be used to reduce pain and discomfort, by mechanical, physiological and neurological pathways to optimize joint mobility; allowing patients to better adhere to a variety of exercises that optimize their quality of life.
This approach may be useful in pain management, movement impairment and when Pharmaceutical interventions are contraindicated.
R V Briani, A S Ferreira, M F Pazzinatto, E Pappas, D De Oliveira Silva, F Nicolis de Azevedo. 2018 What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systemic review with meta-analysis of primary outcomes from randomized controlled trials. BJSM.52 (16)
C A Courtney, A D Steffen, C Fernández de-las-Peñas, J Kim, S J Chemell. 2016. Joint mobilization enhances mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee, JOSPT, 46(3): 168-176.
M Fransen, S McConell, A R Harmer, M Van der Esch, MSimic, KL Bennell. 2015 Exercise for osteoarthritis of the knee: a Cochrane systemic review. BJSM.49: 1554-1557
R B Ferraz, B Gualano, R Rodrigues, C O Kurimori, R Fuller, FR Lima, A L De Sápinto, H Roschel. 2018. Benefits of resistance training with blood flow restriction in knee osteoarthritis. BJSM. 50 (5): 897-905
K Itch, S Hirota, Y Katsumi, H Ochi, H Kitakoii . 2008 Trigger point acupuncture for treatment of knee osteoarthritis- a preliminary RCT for a pragmatic trial. Acupuncture in Medicine. BMJ. 26 (1): 17-26
Y Neelapala, V Raghava, B Madhura, S Purvi. 2018. Hip Muscle Strengthening for Knee Osteoarthritis. Journal of Geriatric Physical Therapy. Nov 6 Volume published ahead of print.
H Pollard, G Ward, W Hoskins, K Hardy. 2008 The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomized control trial. Journal of Canadian Chiropractic Association. 52(4:)229-242.
J G Quicke, N E Foster, M J Thomas, M A Holden. 2015. Is long-term physical activity safe for older adults with knee pain?: a systemic review. Osteoarthritis Cartilage. 23(9): 1445-1456.
H Takasaki.T Hall, G Jull. 2013. Immediate and short-term effects of Mulligan’s mobilization with movement on knee pain and disability associated with knee osteoarthritis- A prospective case series. Physiotherapy Theory and Practice. 29(2): 87-95
A Teichtahl, A Wluka, F M Cicuttini. 2003.Abnormal biomechanics: a precursor or result of knee osteoarthritis. BJSM. 37:28:289-290
E Tukmaci, R Jubb, E Dempsey, P Jones. 2004 The effect of acupuncture on the symptoms of knee osteoarthritis. Acupuncture in Medicine. BMJ. 22 (1): 14-22.
Knee Osteoarthritis treatments are available with Raymond Smith, Chiropractor, 114 Alexander Street, Crows Nest, NSW 2065
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